Letter to the editor
Written in stone: a clinical case of compulsive note taking
JOÃO RICARDO MENDES DE OLIVEIRA
1, ANA GABRIELA HOUNIE
2, MATHEUS FERNANDES DE OLIVEIRA
31 Neuropsychiatric Department, Federal University of Pernambuco (UFPE), Recife, PE, Brazil. 2 Department of Psychiatry, Federal University of São Paulo (Unifesp), São Paulo, SP, Brazil.
3 Neurosurgery Residency Program, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil.
Received: 8/22/14 – Accepted: 9/15/14
DOI: 10.1590/0101-60830000000029
Address correspondence to: Matheus Fernandes de Oliveira. Departamento de Neurocirurgia, Hospital do Servidor Público Estadual de São Paulo. Rua Pedro de Toledo, 1800, Vila Clementino –
04029-000 – São Paulo, SP, Brazil. Telephone: +55 (11) 98546-7815/Telefax: +55 (11) 5088-8379. Email: mafernoliv@yahoo.com.br
Dear Editor
We report the clinical case of a 49 year-old housewife with OCD who, 8 years ago, developed compulsions for taking notes in a notepad of almost every phrase, car plates, random words or numbers that she would place her eyes on, including the ones found in plastic bags and clothing. She started to walk on the streets staring at the loor to avoid seeing new words or numbers she would feel urged and compelled to write down. he patient would even take notes of the serial number of every bill handled during the day. Despite having the clear insight that this was unnecessary, she argued that could not resist keeping doing it because of the putative need to access this information later. he patient even started to request the help from other family members to help with this task.
Such symptoms started ater a quarrel about a foster daughter under her guard, adopted from a sibling who refused to be responsible for the newborn 15 years ago. he patient was always very concerned that the “real” mother could show up anytime and take the child away from her, thus never telling her daughter that she was adopted. Nevertheless, as the biological mother of her daughter came back to her home town ater leaving for more than a decade, she was inally confronted by her daughter regarding the adoption. he patient was afraid to lose the child to the original biological mother. Ater clarify-ing the adoption process, her daughter apparently understood the whole situation and kept in good terms with the foster mother, and avoiding any contact with the biological mother. It is intriguing that her symptoms could be psychodynamically linked to the challenge she was facing. She was keeping record of every note , even useless information, as if she wanted to make sure that the agreement settled several years ago would be actually irreversible and “written in stone”.
his patient improved dramatically with paroxetine (40 mg/day), ceasing most note taking. She presented a noticeable and maintained response to treatment, especially 1 month ater the beginning of drug therapy. Most obsessions concerning taking notes stopped progres-sively and a general relief feeling was mentioned at the follow-up. Drug therapy with paroxetine was maintained all these years. We have tried to increase dosage to a maximum limit but there was no additional efect. However, the patient could not stop to record the time she went to bed, at the end of the day. Nowadays, she persists complaining that this is the only ritual she was not able to quit.
Besides that, she started complaining of memory failure, espe-cially short term memory events, in daily events of routine house management. A neurologic evaluation was performed by assistant
clinicians that excluded organic causes. hey linked the inding as a probable OCD associated memory impairment, oten reported in chronic patients1. here is a current investment in therapy for this patient, in order to improve remaining symptoms.
Movement disorders such as disturbances of ine motor coordina-tion are a frequent phenomenon in patients with obsessive-compulsive disorder (OCD), suggesting involvement of basal ganglia circuitry2-5.
here are few studies on such underrepresented form of OCD (note taking) and a few authors studied the kinematic analysis of handwriting movements in patients with obsessive-compulsive disorder2-5. OCD patients usually write and draw slower and less automatically than do control patients, with lower peak velocity while writing and sometimes presenting with micrographia, without lateralization asymmetry3. Handwriting symptoms are usually more accentuated in early-onset OCD. Handwriting disturbances are also associated with worse therapeutic responses5. Nevertheless, such symptoms may improve with serotonin-enhancing therapy, similarly to the present case4.
Additional case descriptions would be welcome to compile data about how common may be such clinical variety of OCD.
Conlicts of interest
he authors have no conlicts of interest to declare.
References
1. Weber F, Hauke W, Jahn I, Stengler K, Himmerich H, Zaudig M, et al. Does “thinking about thinking” interfere with memory? An expe-rimental memory study in obsessive-compulsive disorder. J Anxiety Disord. 2014;28(7):679-86.
2. Stein DJ. Handwriting and obsessive-compulsive disorder. Lancet. 2001;358(9281):524-5.
3. Mavrogiorgou P, Mergl R, Tigges P, El Husseini J, Schröter A, Juckel G, et al. Kinematic analysis of handwriting movements in patients with obsessive-compulsive disorder. J Neurol Neurosurg Psychiatry. 2001;70(5):605-12.
